Physical Examination Form Page 2
ADVERTISEMENT
1
2PHYSICAL EXAMINATION FORM
Height
Weight
BP
/
T
Pulse
R
Visual Acuity
R 20 /
L 20 /
Corrected: Y
N
Pupils
Normal
Abnormal
Ears, Nose, Throat
Cardiopulmonary
Pulses
Heart
Lungs
Skin
Abdominal
Genitalia
Musculoskeletal
Neck
Shoulder
Elbow
Wrist
Hand
Back
Knee
Ankle
Foot
CLEARANCE / RECOMMENDATIONS
Clearance:
A.
Cleared for all sports and other school-sponsored activities.
B.
Cleared after completing evaluation / rehabilitation for:
C.
NOT cleared to participate in the following IHSAA sponsored sports:
Baseball
Wrestling
Golf
Softball
Track
Cross Country
Basketball
Football
Soccer
Tennis
Volleyball
NOT cleared for other school-sponsored activities:
(
)
1.
2.
3.
Example: Swimming
Student is NOT permitted to participate in high school athletics.
D.
Reason:
Recommendation:
Examiner's Signature:
Date:
(This Physical form must be signed by a licensed physician, physician's assistant or nurse practitioner)
Address:
Phone: (
)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical